Sterilisation judgment: Beginning of a longer battle to reorient family planning programme

In
April 2012, Salamuni and her husband, a rickshaw puller based in
Bundelkhand, visited a hospital in Chitrakoot. She was pregnant and ill,
and they assumed she would get better medical treatment there. The
doctor on call, Ranjana Sharma, was aggressive in her attempts to
convince Salamuni to have a sterilisation operation. Despite Salamuni
insisting that she was too weak, Sharma made her sign a document, gave
her an injection, and initiated an abortion as well as sterilisation
before the anaesthesia kicked in. According to Salamuni’s account, the
doctor spent three hours pumping air into her to locate the nerve, and
when she screamed from the pain, the sari she was wearing was stuffed in
her mouth before she lost consciousness. She had to spend eight days
recovering at a hospital in Allahabad after the ordeal because the
bleeding wouldn’t stop, she told activists from Sahayog, a women’s
reproductive health advocacy group.

Salamuni’s case was an extreme version of the scores of botched
sterilisation jobs that are frighteningly common in India. Earlier this
year, the central government reported 113 deaths caused by tubectomy
surgeries in the last year, but several women’s health activists have
rejected this as a conservative estimate, and the National Alliance on
Maternal Health and Human Rights (NAMHHR) suggested during a press
conference last Friday that approximately 1,000 of the 4 to 5 million
women who undergo sterilisation die every year. This has been attributed
to the appalling conditions under which the abdominal operation is
conducted – often in dharamshalas, under torchlight at night, sometimes
with very poor hygiene and unsanitary tools like bicycle pumps and rusty
scalpels.

The particularly horrific case of the 18 women who died in 2014 after
contracting septicemia and other complications in a sterilisation camp
in Bilaspur, Chhattisgarh is now widely known. RK Gupta, the doctor who
operated on 83 of those women over five hours was briefly put in police
custody but then released because of insufficient evidence. The news
that in the same year he had been rewarded for his ‘record’ career of
50,000 surgeries only epitomises the target-obsessed mentality of the
Family Planning programme.

It was the gory details of a similar incident that took place four years
ago — when 53 Dalit and Scheduled Caste women were operated on at night
in a government school in Araria, Bihar — that convinced the Supreme
Court last week to direct the Centre to end sterilisation camps across
the country, acting on a petition filed in 2012 by health rights
activist Devika Biswas. Activists working on maternal health and human
rights have since organised meetings to discuss the implications of the
judgment. While they welcomed the decision, they were not optimistic
about the 3-year transition period which the Court provided the Centre,
and said that until an actual blueprint is written out to end these mass
camps, it is difficult to say what impact the judgement will have.

Kavita Krishnan, Secretary of the All India Progressive Women’s
Association and member of the CPM pointed out at the conference that the
family planning debate is still very much centred on tackling
population control rather than focusing on women’s reproductive rights:
"The question [should not be] about which is the next best technological
fix in contraception but about what actions will empower women to gain
control over their bodies, and encourage men to take responsibility for
contraception," she said. Unfortunately, the focus on population control
has governed family planning since the late 80s, ever since the Pomeroy
method of tubal ligation through laparoscopy made abdominal operations
easier to conduct. And as Deepa Dhanraj’s 1991 film Something Like A War
shows, doctors had begun conducting them in unsanitary situations early
on: “I spend 45 seconds per operation. I have conducted 3,13,939
operations, this year, more than two thousand in schools and government
halls…” says one gynaecologist in the film.

Abhijit Das, co-founder of Healthwatch Forum and a trained doctor
working at the Centre for Health and Social Justice in Delhi, added that
paranoia about the population explosion has been so deeply ingrained in
the public mindset that the government feels justified in its search
for quick-fix solutions. The alternative, he says, is aiming for
population growth to be spread over years: “India has a very young
population. What you want is for reproduction to take place over time,
rather than people having many babies and getting sterilised at 24.
Sterilisation should also happen later because it has been associated
with high regret and hysterectomy rates.”

One of the most crucial questions that was raised at the NAMHHR
conference concerned the (lack of) temporary contraceptive and
alternatives in the family planning programme. The post-partum
intra-uterine contraceptive device (PPIUCD) is another measure that has
been gaining popularity. Rajdev Chaturvedi, from the Gramin Punarnirman
Sansthan in Azamgarh, Uttar Pradesh, spoke about increasing cases of the
device being inserted without women’s consent or knowledge after they
give birth. He was also skeptical about the impact of the judgment,
claiming that the real change would involve the improvement of access to
counselling for women regarding contraception, as at the moment they
are targeted while they are vulnerable and in pain during deliveries.

Jashodhara Dasgupta, a coordinator of Sahayog who also works with
Healthwatch Forum, UP, emphasised the importance of expanding the
objectives of family planning to include a variety of contraceptives so
that women can make “informed choices”. These include measures for those
who find the PPIUCD invasive or adolescents at the start of their
sexual lives, for whom sterilisation is entirely unnecessary. “The
government has put off a long-term vision that encompasses the diversity
of people’s needs for so long,” she said.

But the reason that non-consensual sterilisation is so rampant in the
first place is because doctors are given annual (unofficial) targets or
ELAs (Expected Levels of Achievement) to fulfil. Although the recent
Supreme Court judgement directs the government against encouraging
“incentivised consent” or setting even informal targets for health
workers, this may well conflict with India’s commitment to providing
contraceptive services to 48 million additional users as part of its
family planning goals for 2020. And as of last year, more than 80
percent of the annual family planning budget was spent on promoting
sterilisation. Even though the most recent National Family Health Survey
statistics suggest that female sterilisation has decreased overall in
many states in the last decade, in states like Andhra Pradesh, as many
as 68.3 percent of women across rural and urban areas have undergone
sterilisation — it doesn’t look like a problem that can be completely
eradicated right away.

It
remains to be seen, then, whether this judgement will be the beginning
of a much longer battle to reorient the family planning programme.

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